Illinois Medicare Fraud Defense

Illinois is home to some of the nation’s leading health care facilities. It is also one of the states at the center of the federal government’s fight against Medicare fraud. If your business or practice is under investigation, call Oberheiden, P.C. at 888-680-1745 for a confidential case assessment.

Medicare-participating health care providers in Illinois are subject to close and constant scrutiny by the federal government. Through automated review of program billing data, reliance on “fee-for-service” audit contractors, and devotion of substantial government resources to identifying fraudulent program billings, the federal government is aggressively targeting Illinois health care providers for civil – and in some cases criminal – prosecution.

Medicare fraud is a serious allegation. An allegation of Medicare fraud is an allegation that your business or practice has billed the government for money it does not owe. But, despite the severity of these allegations, they are extraordinarily common, and Illinois health care providers are being targeted in Medicare fraud investigations with increasing frequency.

If your health care business or medical practice is under investigation, you need experienced legal representation. If federal prosecutors find evidence of fraud, they will pursue charges, and Medicare participants can face severe punishment even for unintentional billing violations. At Oberheiden, P.C., our federal health care fraud defense attorneys have centuries of combined experience representing providers nationwide, and we have a proven track record of success which includes resolving the substantial majority of our clients’ cases prior to trial.

Our Medicare fraud defense practice consists of representing physicians, pharmacists, clinicians, practice owners, facility administrators, company executives, board members, and other individuals and entities in investigations, grand jury proceedings, trials, and appeals. We handle civil and criminal cases involving all relevant federal statutes (including the False Claims Act, the Anti-Kickback Statute, the Stark Law, and the federal health care fraud statute (18 U.S.C. § 1347)), and all investigating agencies and task forces. This includes representing health care providers in Illinois and other jurisdictions who are under investigation by authorities including:

Centers for Medicare and Medicaid Services (CMS)

Department of Justice (DOJ)

Department of Health and Human Services Office of Inspector General (OIG)

Federal Bureau of Investigation (FBI)

Internal Revenue Service (IRS)

Medicare Fraud Strike Force

The Medicare Fraud Strike Force is a joint task force comprised of agents and prosecutors from the DOJ, OIG, FBI, and other federal, state, and local agencies. It currently has full-time operations in 14 locations around the country, including Chicago, Illinois. With its stated mission to, “harness data analytics and the combined resources of Federal, State, and local law enforcement entities to prevent and combat health care fraud, waste, and abuse,” the Medicare Fraud Strike Force routinely targets legitimate health care providers based solely on apparent “anomalies” in their Medicare program billing data.

In-Depth Knowledge of the Legal and Health Care Issues Related to Medicare Billing and Compliance

Despite the extraordinary complexity of the Medicare billing regulations and the plethora of federal statutes that govern providers who bill Medicare and other federal health care benefit programs, most Medicare fraud investigations tend to focus on a list of common billing and coding-related allegations. Our attorneys are intimately familiar with the government’s most-common allegations against participating providers as well as the more-nuanced allegations that come up less frequency but which present equal risks for providers targeted by the DOJ, OIG, Medicare Fraud Strike Force, and other federal authorities.

With our attorneys’ in-depth knowledge of the legal and health care-related considerations involved in billing Medicare for patient services, medical equipment, and supplies, we are able to skillfully and efficiently represent clients who are being accused of billing and coding violations such as:

Billing for services at a higher rate than the one allowed (referred to as “upcoding”)

Billing for related services and supplies at individual, rather than bundled, rates (referred to as “unbundling”)

Billing for services not actually rendered

Billing for services that do not qualify as “medically necessary” under the Medicare billing guidelines

Double-billing Medicare and other public and private insurers for services, equipment, and supplies

Inflating charges, making unnecessary use of medical equipment, and misrepresenting test results

Paying illegal referral fees, rebates, and other forms of “remuneration” out of Medicare-reimbursed funds

When defending against allegations of Medicare fraud, a provider’s defense strategy must be custom-tailored to the specific allegations at hand as well as the potential penalties and the outcome desired. At Oberheiden, P.C., we work closely with our clients to develop and execute case strategies that are designed to secure a favorable result as efficiently as possible.

1. Potential Defenses

In Medicare fraud cases, potential defenses fall into three categories: (i) evidentiary, (ii) affirmative, and (iii) constitutional. In appropriate circumstances, our attorneys utilize defenses in each of these categories to protect our clients at the investigative stage, during pre-trial proceedings, and at trial.

Evidentiary Defenses – In civil cases, the government must prove liability beyond a preponderance of the evidence. In criminal cases, it must prove guilt beyond a reasonable doubt. By challenging the admissibility and sufficiency of the government’s evidence, we can often build a convincing argument that prosecution would not result in a conviction if the case were taken to trial. While demonstrating flaws in even a single element of the government’s case is sufficient (i.e. challenging evidence of intent in criminal prosecutions), we take a comprehensive approach designed to expose as many flaws in the government’s case as possible.

Affirmative Defenses – In Medicare fraud cases, the primary affirmative defenses are the “safe harbor” provisions under the Anti-Kickback Statute and the Stark Law. By asserting these statutory safe harbors in appropriate cases, we can protect our clients even in circumstances where the government’s evidence is sufficient to facially establish a statutory violation.

Constitutional Defenses – Constitutional defenses provide protection by stopping illegally-obtained evidence from being admitted at trial. This includes records and testimony, and it applies primarily in cases where authorities unlawfully seize documents or computers without a warrant or violate a witness’s or suspect’s right to counsel or privilege against self-incrimination.

2. Potential Penalties

The potential penalties in Medicare fraud cases depend on a variety of factors, most notably whether the case is civil or criminal in nature. Beyond this, the specific allegations are relevant as well, as is the volume of the unlawful billings alleged. Since certain financial penalties apply on a “per-claim” basis (and each individual billing constitutes a separate “claim”), providers accused of submitting hundreds or thousands of improper reimbursement requests will generally have far greater exposure than providers who are being targeted for a lesser number of violations.

Broadly speaking, the potential penalties for Medicare fraud include:

Civil Medicare Fraud Penalties

Recoupment of overbilled amounts

Denial of pending claims

Pre-payment review of future claims

Civil fines

Treble (triple) damages

Attorneys’ fees

Exclusion from Medicare participation

Criminal Medicare Fraud Penalties

Criminal fines

Federal imprisonment (including the potential for life imprisonment in cases where fraudulent Medicare practices result in a patient’s death)

Exclusion from Medicare participation and other program-related penalties

Critically, these are only the penalties for civil and criminal offenses that are specific to Medicare fraud. In a criminal case where federal prosecutors also pursue charges for mail fraud, wire fraud, money laundering, tax evasion, and other crimes (as is often the case), Illinois health care providers can face substantial additional fines and terms of imprisonment.

3. Potential Outcomes

Similar to penalties, the potential outcomes in Medicare fraud investigations are heavily dependent upon the specific facts and circumstances involved. While the ideal scenario is to close the government’s investigation without any civil or criminal charges or liability (a result which our attorneys have obtained in many cases), this result may not be feasible given the evidence at hand. That said, there are several other potential outcomes short of a criminal conviction resulting in federal incarceration; and, when necessary, we tailor our defense strategies to minimizing the consequences of our clients’ investigations to the greatest extent possible.

Once again depending on the circumstances involved, a favorable outcome in a Medicare fraud investigation could mean:

Oberheiden, P.C. is a federal health care fraud defense law firm with a nationwide presence. As a result of our extensive track record and our attorneys’ vast experience on both sides of Medicaid fraud investigations and trials, we have become go-to defense counsel for health care providers in Illinois and nationwide. Click to learn more about our federal health care fraud defense lawyers, then contact us to schedule a free and confidential initial consultation.

Impeccable Service

ratingratingratingratingrating

Nick Oberheiden is the absolute best federal litigation attorney. Nick gives you the immediate comfort of feeling 100% protected. He is polite, respectful— and extremely compelling. His legal strategy turned out to be brilliant.

Attorney advertising. Prior results do not guarantee similar outcome. NOTICE: All visitors to this Website are informed that Oberheiden, P.C. (“Firm”) affiliates with independent and separate attorneys (“Local Counsel”) and their respective law firms on a case by case basis. If and when this applies to a particular client, we will disclose the details to client in writing for their approval. In some cases, pursuant to Rule 7.04 of the Texas Disciplinary Rules of Professional Conduct and the equivalent in other jurisdictions, a case is referred to a Local Counsel, the Firm will not participate in the representation. In such a case, client will sign an engagement exclusively with the Local Counsel.